Provider Demographics
NPI:1215212642
Name:CHANDLER, OTIS (LCSW)
Entity Type:Individual
Prefix:MR
First Name:OTIS
Middle Name:
Last Name:CHANDLER
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 HIDDEN CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7595
Mailing Address - Country:US
Mailing Address - Phone:404-664-4517
Mailing Address - Fax:
Practice Address - Street 1:5960 CROOKED CREEK RD
Practice Address - Street 2:SUITE 140-F
Practice Address - City:PEACHTREE CORNERS
Practice Address - State:GA
Practice Address - Zip Code:30092-6219
Practice Address - Country:US
Practice Address - Phone:404-664-4517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2017-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD17210104100000X
GACSW0059891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker